Common use of Establishment of UR/QM Programs Clause in Contracts

Establishment of UR/QM Programs. Utilization review and quality management programs shall be established to review whether services rendered by PROVIDER were Medically Appropriate and to determine the quality of Covered Services furnished by PROVIDER to Members. Such programs will be established by XXXXX, in its sole and absolute discretion, and will be in addition to any utilization review and quality management programs required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal, shall be bound by all such utilization review and quality management programs. If requested, PROVIDER may serve on the utilization review and/or quality management committee of such programs in accordance with the procedures established by XXXXX and Plans. Failure to comply with the requirements of this paragraph may be deemed by XXXXX to be a material breach of this Agreement and may, at XXXXX’ option, be grounds for immediate termination by XXXXX of this Agreement. PROVIDER agrees the decisions of the XXXXX designated utilization review and quality management committees may be used by XXXXX to deny PROVIDER payment for services rendered to a Member which are determined to not be Medically Appropriate or of poor quality or to be services for which PROVIDER failed to receive a confirmation of eligibility prior to rendering services.

Establishment of UR/QM Programs. Utilization review and quality management programs shall be established to review whether services rendered by PROVIDER were Medically Appropriate and to determine the quality of Covered Services furnished by PROVIDER to Members. Such programs will be established by XXXXX, in its sole and absolute discretion, and will be in addition to any utilization review and quality management programs required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal, shall be bound by all such utilization review and quality management programs. If requested, PROVIDER may serve on the utilization review and/or quality management committee of such programs in accordance with the procedures established by XXXXX and Plans. Failure to comply with the requirements of this paragraph may be deemed by XXXXX to be a material breach of this Agreement and may, at XXXXX’ option, be grounds for immediate termination by XXXXX of this Agreement. PROVIDER agrees the decisions of the XXXXX designated utilization review and quality management committees may be used by XXXXX to deny PROVIDER payment hereunder for services rendered those Covered Services provided to a Member which are determined to not be Medically Appropriate or of poor quality or to be services for which PROVIDER failed to prior receive a confirmation of eligibility prior to rendering servicestreat a Member.

Establishment of UR/QM Programs. Utilization review and quality management programs shall be established to review whether services rendered by PROVIDER were Medically Appropriate and to determine the quality of Covered Services furnished by PROVIDER to Members. Such programs will be established by XXXXX, in its sole and absolute discretion, and will be in addition to any utilization review and quality management programs required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal, shall be bound by all such utilization review and quality management programs. If requested, PROVIDER may serve on the utilization review and/or quality management committee of such programs in accordance with the procedures established by XXXXX and Plans. Failure to comply with the requirements of this paragraph may be deemed by XXXXX to be a material breach of this Agreement and may, at XXXXX’ option, be grounds for immediate termination by XXXXX of this Agreement. PROVIDER agrees the decisions of the XXXXX designated utilization review and quality management committees may be used by XXXXX to deny PROVIDER payment for those services rendered to a Member which are determined to not be Medically Appropriate or of poor quality or to be services for which PROVIDER failed to receive a confirmation of eligibility prior to rendering services.

Establishment of UR/QM Programs. Utilization review and quality management programs shall be established to review whether services rendered by PROVIDER were Medically Appropriate and to determine the quality of Covered Services furnished by PROVIDER to Members. Such programs will be established by XXXXX, XXXXX in its sole and absolute discretion, and will be in addition to any utilization review and quality management programs required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal, shall be bound by all such utilization review and quality management programs. If requested, PROVIDER may serve on the utilization review and/or quality management committee of such programs in accordance with the procedures established by XXXXX and Plans. Failure to comply with the requirements of this paragraph may be deemed by XXXXX to be a material breach of this Agreement and may, at XXXXX’ option, be grounds for immediate termination by XXXXX of this Agreement. PROVIDER agrees the decisions of the XXXXX designated utilization review and quality management committees may be used by XXXXX to deny PROVIDER payment for services rendered to a Member which are determined to not be Medically Appropriate or of poor quality or to be services for which PROVIDER failed to receive a confirmation of eligibility prior to rendering services.

Establishment of UR/QM Programs. Utilization review and quality management programs shall be established to review whether services rendered by PROVIDER were Medically Appropriate and to determine the quality of Covered Services furnished by PROVIDER to Members. Such programs will be established by XXXXX, in its sole and absolute discretion, and will be in addition to any utilization review and quality management programs required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal, shall be bound by all such utilization review and quality management programs. If requested, PROVIDER may serve on the utilization review and/or quality management committee of such programs in accordance with the procedures established by XXXXX and Plans. Failure to comply with the requirements of this paragraph may be deemed by XXXXX to be a material breach of this Agreement and may, at XXXXX’ option, be grounds for immediate termination by XXXXX of this Agreement. PROVIDER agrees the decisions of the XXXXX designated utilization review and quality management committees may be used by XXXXX to deny PROVIDER payment for services rendered to a Member which are determined to not be Medically Appropriate Appropriate, or of poor quality quality, or to be services for which PROVIDER failed to receive a confirmation of eligibility prior to rendering services.

Establishment of UR/QM Programs. Utilization review and quality management programs shall be established to review whether services rendered by PROVIDER were Medically Appropriate and to determine the quality of Covered Services furnished by PROVIDER to Members. Such programs will be established by XXXXX, in its sole and absolute discretion, and will be in addition to any utilization review and quality management programs required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal, shall be bound by all such utilization review and quality management programs. If requested, PROVIDER may serve on the utilization review and/or quality management committee of such programs in accordance with the procedures established by XXXXX and Plans. Failure to comply with the requirements of this paragraph paragrph may be deemed by XXXXX to be a material breach of this Agreement and may, at XXXXX’ option, be grounds for immediate termination by XXXXX of this Agreement. PROVIDER agrees the decisions of the XXXXX designated utilization review and quality management committees may be used by XXXXX to deny PROVIDER payment hereunder for services rendered those Covered Services provided to a Member which are determined to not be Medically Appropriate or of poor quality or to be services for which PROVIDER failed to receive a prior confirmation of eligibility prior to rendering servicestreat a Member.

Establishment of UR/QM Programs. Utilization review and quality management programs shall be established to review whether services rendered by PROVIDER were Medically Appropriate and to determine the quality of Covered Services furnished by PROVIDER to Members. Such programs will be established by XXXXX, in its sole and absolute discretion, and will be in addition to any utilization review and quality management programs required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal, shall be bound by all such utilization review and quality management programs. If requested, PROVIDER may serve on the utilization review and/or quality management committee of such programs in accordance with the procedures established by XXXXX and Plans. Failure to comply with the requirements of this paragraph may be deemed by XXXXX to be a material breach of this Agreement and may, at XXXXX’ option, be grounds for immediate termination by XXXXX of this Agreement. PROVIDER agrees the decisions of the XXXXX designated utilization review and quality management committees may be used by XXXXX to deny PROVIDER payment for services rendered to a Member which are determined to not be Medically Appropriate or of poor quality or to be services for which PROVIDER failed to receive a confirmation of eligibility prior to rendering services.

Establishment of UR/QM Programs. Utilization review and quality management programs shall be established to review whether services rendered by PROVIDER were Medically Appropriate and to determine the quality of Covered Services furnished by PROVIDER to Members. Such programs will be established by XXXXX, in its sole and absolute discretion, and will be in addition to any utilization review and quality management programs required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal, shall be bound by all such utilization review and quality management programs. If requested, PROVIDER may serve on the utilization review and/or quality management committee of such programs in accordance with the procedures established by XXXXX and Plans. Failure to comply with the requirements of this paragraph may be deemed by XXXXX to be a material breach of this Agreement and may, at XXXXX’ option, be grounds for immediate termination by XXXXX of this Agreement. PROVIDER agrees the decisions of the XXXXX designated utilization review and quality management committees may be used by XXXXX to deny PROVIDER payment hereunder for services rendered those Covered Services provided to a Member which are determined to not be Medically Appropriate or of poor quality or to be services for which PROVIDER failed to receive a confirmation of eligibility prior to rendering servicestreat a Member.

Establishment of UR/QM Programs. Utilization review and quality management programs shall be established to review whether services rendered by PROVIDER were Medically Appropriate and to determine the quality of Covered Services furnished by PROVIDER to Members. Such programs will be established by XXXXX, in its sole and absolute discretion, XXXXX and will be in addition to any utilization review and quality management programs required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal, shall be bound by all such utilization review and quality management programs. If requested, PROVIDER may serve on the utilization review and/or quality management committee of such programs in accordance with the procedures established by XXXXX and Plans. Failure to comply with the requirements of this paragraph may be deemed by XXXXX to be a material breach of this Agreement and may, at XXXXX’ option, be grounds for immediate termination by XXXXX of this Agreement. PROVIDER agrees the that decisions of the XXXXX designated utilization review and quality management committees may be used by XXXXX to deny PROVIDER payment hereunder for services rendered those Covered Services provided to a Member which are determined to not be Medically Appropriate or of poor quality or to be deny up to fifty percent (50%) of payment for services for which PROVIDER failed to receive a confirmation of eligibility prior to rendering services.

Establishment of UR/QM Programs. Utilization review and quality management programs shall be established to review whether services rendered by PROVIDER were Medically Appropriate and to determine the quality of Covered Services furnished by PROVIDER to Members. Such programs will be established by XXXXX, in its sole and absolute discretion, and will be in addition to any utilization review and quality management programs required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal, shall be bound by all such utilization review and quality management programs. If requested, PROVIDER may serve on the utilization review and/or quality management committee of such programs in accordance with the procedures established by XXXXX and Plans. Failure to comply with the requirements of this paragraph may be deemed by XXXXX to be a material breach of this Agreement and may, at XXXXX’ option, be grounds for immediate termination by XXXXX of this Agreement. PROVIDER agrees the decisions of the XXXXX designated utilization review and quality management committees may be used by XXXXX to deny PROVIDER payment hereunder for services rendered those Covered Services provided to a Member which are determined to not be Medically Appropriate or of poor quality or to be services for which PROVIDER failed to receive a confirmation of eligibility prior to rendering services.

Establishment of UR/QM Programs. Utilization review and quality management programs shall be established to review whether services rendered by PROVIDER were Medically Appropriate and to determine the quality of Covered Services furnished by PROVIDER to Members. Such programs will be established by XXXXX, in its sole and absolute discretion, and will be in addition to any utilization review and quality management programs required by a Plan. PROVIDER shall comply with and, subject to PROVIDER’s rights of appeal, shall be bound by all such utilization review and quality management programs. If requested, PROVIDER may serve on the utilization review and/or quality management committee of such programs in accordance with the procedures established by XXXXX and Plans. Failure to comply with the requirements of this paragraph Section IX.3 may be deemed by XXXXX to be a material breach of this Agreement and may, at XXXXX’ option, be grounds for immediate termination by XXXXX of this Agreement. PROVIDER agrees the that decisions of the XXXXX designated utilization review and quality management committees may be used by XXXXX to deny PROVIDER payment hereunder for services rendered those Covered Services provided to a Member which are determined to not be Medically Appropriate or of poor quality or to be services for which PROVIDER failed to receive a confirmation of eligibility prior authorization to rendering servicestreat a Member.